Presentation
Worsening left hemiparesis for several days.
Patient Data
There are multiple lesions in the supra and infratentorial brain. The dominant lesion is in the right centrum semiovale, with concentric rings of heterogeneous T1 hypointensity and T2/FLAIR hyperintensity. This lesion demonstrates patchy enhancement, with vivid abormal diffusion restriction (ADC value: ~250). There are multiple other smaller lesions, the larger ones which demonstrate a similar pattern - left centrum semi ovale, left cerebral crus, left hemipons. No susceptibility artifact. Normal visualized intracranial MRA. Incidental fluid filled sphenoid.
Case Discussion
The concentric onion ring pattern of these lesions is characteristic of Balo concentric sclerosis. This is a variant of demyelination with the alternating intralesional intensities representing myelinated and demyelinated axons 1. The regions of true diffusion restriction reflect active demyelination. Over time, the onion ring plaques coalesce to form more homogeneous T2 hyperintense plaques.
Although typically described in young adults, pediatric cases are not uncommon 2.
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